Pharmacologic class: Receptor tyrosine kinase inhibitor
Therapeutic class: Antineoplastic
Pregnancy risk category D
FDA Box Warning
• Hepatotoxicity, which has been observed in clinical trials and postmarketing experience, may be severe, and deaths have occurred.
Inhibits multiple receptor tyrosine kinases, some of which are implicated in tumor growth, pathologic angio-genesis, and metastatic cancer progression
Capsules: 12.5 mg, 25 mg, 50 mg
⊘Indications and dosages
➣ GI stromal tumor after disease progression with or intolerance to imatinib mesylate; advanced renal cell carcinoma
Adults: 50 mg P.O. daily on cycle of 4 weeks on and 2 weeks off treatment; may increase or decrease dosage in 12.5-mg increments based on safety and tolerance
• Concurrent use of strong CYP3A4 inducers or inhibitors
• Hypersensitivity to drug or its components
Use cautiously in:
• left ventricular dysfunction, hypertension, history of prolonged QT interval, concurrent use of antiarrhythmics, patients with relevant preexisting cardiac disease, bradycardia, or electrolyte disturbances
• patients who have experienced cardiac events within previous 12 months
• concurrent use of strong CYP3A4 inhibitors
• pregnant or breastfeeding patients
• children (safety and efficacy not established).
☞ Monitor liver function tests before start of treatment.
• Administer with or without food.
• Interrupt therapy or reduce dosage, as prescribed, in patients who lack clinical evidence of heart failure but have ejection fractions (EFs) below 50% and above 20% below baseline.
CNS: headache, asthenia
CV: hypertension, left ventricular dysfunction
EENT: epistaxis, oral pain
GI: nausea, vomiting, diarrhea, constipation, abdominal pain, mucositis, stomatitis, anorexia
Hematologic: bleeding, anemia, thrombocytopenia, neutropenia, lymphopenia, hemorrhage
Metabolic: acquired hypothyroidism, adrenal toxicity
Musculoskeletal: arthralgia, back pain, limb pain, myalgia
Respiratory: dyspnea, cough, pulmonary embolism
Skin: skin abnormalities, skin discoloration, rash, palmar-plantar erythrodysesthesia, alopecia, hair color changes
Other: altered taste, fatigue, fever
Drug-drug.Atazanavir, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, voriconazole: increased sunitinib blood level
Carbamazepine, dexamethasone, phenobarbital, phenytoin, rifabutin, rifampin, rifapentin: decreased sunitinib blood level
Drug-diagnostic tests.Amylase, creatinine, lipase, uric acid: increased
Liver function tests: abnormal
Serum phosphorus, potassium, sodium: decreased
Drug-food.Grapefruit juice, pomegranate: increased sunitinib blood level
Drug-herbs.Alpha-lipoic acid: decreased chemotherapeutic efficacy
American elder, bishop's weed, cat's claw, devil's claw, eucalyptus, feverfew, Siberian ginseng, valerian: increased sunitinib blood level
St. John's wort: unpredictable decrease in sunitinib blood level
• Obtain CBC with platelet count and blood chemistries (including phosphate) at start of each treatment cycle and frequently thereafter.
• Know that physician may order baseline and periodic evaluation of left ventricular EF in patients who experienced cardiac events within 12 months before starting drug. Watch closely for signs and symptoms of left ventricular dysfunction (especially heart failure).
• Be aware that physician may order baseline EF testing for patients without cardiac risk factors.
• Monitor for hypertension; administer standard antihypertensive therapy as ordered and needed.
• Monitor for adrenal insufficiency if patient experiences stress (as from surgery, trauma, or severe infection).
☞ Monitor liver function tests during each cycle of treatment and as clinically indicated. Interrupt therapy for Grade 3 or 4 drug-related hepatic adverse events; discontinue drug if no resolution. Don't restart drug if severe changes in liver function tests subsequently occur or if patient has other signs and symptoms of liver failure.
• Instruct patient to take drug with or without food.
☞ Urge patient to immediately report sudden signs and symptoms of liver problems (such as yellowing of skin or eyes, unusual tiredness, loss of appetite), chest pain, swelling, or difficulty breathing.
• Tell patient drug may cause skin changes (drying, cracking, or rashes on hands or feet) and hair color changes.
• Advise patient to consult prescriber before taking other drugs, including over-the-counter drugs and herbs.
• Caution patient not to take St. John's wort during therapy.
• Advise female with childbearing potential to avoid pregnancy and breastfeeding during therapy.
•As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above.
Pharmacologic: kinase inhibitors
Time/action profile (blood levels)
|PO||unknown||6–12 hr||24 hr|
Adverse Reactions/Side Effects
Central nervous system
- Reversible Posterior Leukoencephalopathy Syndrome (life-threatening)
- fatigue (most frequent)
- chf (life-threatening)
- hypertension (most frequent)
- peripheral edema
- QT interval prolongation
- thromboembolic events
Ear, Eye, Nose, Throat
- epistaxis (most frequent)
- diarrhea (most frequent)
- dyspepsia (most frequent)
- nausea (most frequent)
- stomatitis (most frequent)
- vomiting (most frequent)
- altered taste
- ↑ lipase/amylase
- ↑ liver enzymes
- oral pain
- erythema multiforme (life-threatening)
- hand-foot syndrome
- hair color change
- impaired wound healing
- skin discoloration
- hypothyroidism (most frequent)
- adrenal insufficiency
Fluid and Electrolyte
- anemia (most frequent)
- lymphopenia (most frequent)
- neutropenia (most frequent)
- thrombocytopenia (most frequent)
- hyperuricemia (most frequent)
- back pain
- limb pain
- osteonecrosis (primarily of jaw)
- tumor lysis syndrome (life-threatening)
- fever (most frequent)
Drug-Drug interactionKetoconazole and other inhibitors of the CYP3A4 enzyme system may ↑ levels and the risk of toxicity; ↓ dose to 37.5 mg daily (for GIST and RCC) or 25 mg daily (for pNET); avoid these strong inhibitors, if possible.Rifampin and other inducers of the CYP3A4 enzyme system may ↓ levels and effectiveness; ↑ dose to 87.5 mg daily (for GIST and RCC) or 62.5 mg daily (for pNET); avoid these strong inducers, if possible.Concurrent use with alendronate, etidronate, ibandronate, pamidronate, risedronate, tiludronate, or zoledronic acid may ↑ risk of jaw osteonecrosis↑ risk of microangiopathic hemolytic anemia when used with bevacizumab (concurrent use not recommended).St. John's wort may ↓ levels and effectiveness; avoid concurrent use.Blood levels and effects are ↑ by grapefruit juice; concurrent use should be avoided.
GIST and RCC
- Monitor for signs of HF (dyspnea, edema, jugular venous distention) during therapy. Assess left ventricular ejection fraction (LVEF) at baseline and periodically during therapy in patients with cardiac events in the previous 12 mo and a baseline ejection fraction in patients without cardiovascular risk factors. Discontinue sunitinib if signs of HF occur.
- Monitor for hypertension and treat with standard antihypertensive therapy. If severe hypertension occurs, may discontinue sunitinib until controlled.
- Monitor ECG and electrolytes periodically during therapy; may cause QT prolongation and torsades de pointes.
- Lab Test Considerations: Monitor CBC with platelet count and serum chemistries including phosphate at the beginning of each treatment cycle. May cause neutropenia, lymphopenia, anemia, and thrombocytopenia. May cause ↑ creatinine, hypokalemia, hyperuricemia, and ↑ uric acid.
- Monitor ALT, AST, and bilirubin before starting therapy, during each cycle of treatment, and as clinically indicated. Stop therapy if Grade 3 or 4 drug-related hepatic adverse events occur and discontinue if there is no resolution. Do not restart sunitinib if patients subsequently experience severe changes in liver function tests or have other signs and symptoms of liver failure. May cause ↑ AST, ALT, alkaline phosphatase, total and indirect bilirubin, amylase, and lipase.
- Monitor thyroid function at baseline and in patients with symptoms of hypothyroidism or hyperthyroidism. May be treated with standard medical practice.
Potential Nursing DiagnosesDiarrhea (Adverse Reactions)
Nausea (Adverse Reactions)
- Do not confuse sunitinib with sorafenib.
- Oral: Administer once daily with or without food.
- Instruct patient to take sunitinib as directed. Take missed doses as soon as remembered, but not just before next dose. Take next dose at regular time. Do not take more than 1 dose at a time. Tell your health care professional about the missed dose.
- Advise patient to avoid grapefruit juice and grapefruit products during therapy.
- Instruct patient to notify health care professional promptly if signs of liver failure (itching, yellow eyes or skin, dark urine, pain or discomfort in the right upper stomach area) or tumor lysis syndrome (nausea, shortness of breath, irregular heartbeat, clouding of urine, tiredness) occur.
- Advise patient that GI disorders (diarrhea, nausea, stomatitis, dyspepsia, vomiting) are common and may require antiemetic and antidiarrheal medications.
- Inform patient that sunitinib may cause discoloration (yellow) of skin and depigmentation of hair or skin.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.
- Advise patient to notify health care professional if bleeding or swelling occur.
- Advise women of childbearing potential to avoid becoming pregnant while receiving sunitinib.
- Decrease in tumor spread.